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The E/M service documented is a level two hospital progress note. E/M Insight Case of the Week 99232 $64.76 E/M History Exam MDM Time 99231 PF PF SF/Low 15 99232 EPF EPF Mod 25 99233 Det Det High 35 (Requires 2 out of 3 key components) CHIEF COMPLAINT: Followup chronic kidney disease. INTERVAL HISTORY: The patient's chronic kidney disease remains stable. His hypertension has been well controlled. REVIEW OF SYSTEMS: GENITOURINARY: Negative for flank pain, hematuria, or obstructive symptoms. PHYSICAL EXAMINATION: GENERAL: He is awake and alert in no acute distress. VITAL SIGNS: Show blood pressure of 121/69, respirations 20, and pulse 85. LUNGS: Clear bilaterally. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft. EXTREMITIES: Show no peripheral edema. History HPI ROS PFSH PF Brief None None EPF Brief ≥1 None Detailed Ext 2-9 1/ 3 Comp Ext ≥ 10 3/3 Exam Bullets Required PF 1 - 5 from any organ systems EPF 6 - 11 from any organ systems Detailed ≥ 12 from any organ systems Comp 2 bullets from NINE systems LABORATORY DATA: Laboratory information shows BUN of 24, creatinine of 1.3, and potassium 4.1. Hemoglobin 10.1. IMPRESSION: 1. Chronic kidney disease, which is stable. 2. Hypertension, which is well controlled. 3. Multi-factorial improving anemia. 4. Diabetes with good glycemic control 5. CAD s/p CABG. MDM Prob. Pts Data Pts Risk SF ≤1 ≤1 Min Low 2 2 Low Mod 3 3 Mod High ≥4 ≥4 High Requires 2/3 dimensions PLAN: 1. Continue Procrit. 2. Continue current blood pressure medications unchanged. 3. Continue to monitor electrolytes, fluid balance and renal function while in house. For clinically-driven E/M coding and documentation education, go to www.EMuniversity.com